Clinical Investigation of medicinal products in pediatric poulation

1. CLINICAL
INVESTIGATION OF
MEDICINAL PODUCTS IN
PEDIATRIC POPULATION
Adopted on
18 August 2017
ICH HARMONISED
GUIDELINE - E11 (R1)

2. First
Codifiaction
History Date
New Codification
November 2005
E11
Approval by the Steering Committee under Step 2
and release for public consultation.
7
October
1999
E11
E11
Approval by the Steering Committee under Step 4
and recommendation for adoption to the three ICH
regulatory bodies.
19
July
2000
E11
Code History Date
E11 (R1) Endorsement by the ICH Assembly under Step 2 and release for public consultation.
12 October
2016
E11 (R1)
Adoption by the Regulatory Members of the ICH Assembly under Step 4 (document
dated 20 July 2017)
18 August
2017
Current Step 4 version of the E11(R1)
ICH E11(R1) Document History

3. TABLE
OF
CONTENTS
01
02
03
Introduction
Guidance
Addendum
1 of 33

4. Introduction
o The number of medicinal products currently
labeled for pediatric use is limited.
o It is the goal of this guidance to encourage
and facilitate timely pediatric medicinal
product development internationally.
o The guidance provides an outline of critical
issues in pediatric drug development and
approaches to the safe, efficient, and ethical
study of medicinal products in the pediatric
population.
2 of 33

5. GUIDANCE
02
3 of 33

6. The decision to proceed with a pediatric development program for a medicinal product, and the nature of that program,
involve consideration of many factors, including:
• The prevalence of the condition to be treated in the pediatric population
• The seriousness of the condition to be treated
• The availability and suitability of alternative treatments for the condition in the pediatric population, including the efficacy
and the adverse event profile (including any unique pediatric safety issues) of those treatments
• Whether the medicinal product is novel or one of a class of compounds with known properties
• Whether there are unique pediatric indications for the medicinal product
• The need for the development of pediatric-specific endpoints
• The age ranges of pediatric patients likely to be treated with the medicinal product
• Unique pediatric (developmental) safety concerns with the medicinal product, including any nonclinical safety
issues
• Potential need for pediatric formulation development
i. Issues When Initiating A Pediatric Medicinal Product
Development Program
4 of 33

7. ii. Pediatric
Formulations
5 of 33

8. “There is a need for
pediatric formulations that
permit accurate dosing and
enhance patient
compliance”
6 of 33

9. iii. Timing
of Studies
The timing of pediatric studies
will depend on the medicinal
product, the type of disease
being treated, safety
considerations, and the efficacy
and safety of alternative
treatments.
7 of 33

10. Sr.
No.
Area Timing
Medicinal products for diseases
predominantly or exclusively affecting
pediatric patients
Medicinal Products Intended to Treat
Serious or Life-Threatening Diseases,
Occurring in Both Adults and Pediatric
Patients, for Which There Are
Currently No or Limited Therapeutic
Options
Medicinal Products Intended to
Treat Other Diseases and
Conditions
In this case, the entire development program will be
conducted in the pediatric population except
for initial safety and tolerability data, which will
usually be obtained in adults.
In this case, there is need for relatively urgent and
early initiation of pediatric studies. Medicinal product
development should begin early in the pediatric
population, following assessment of initial safety data
and reasonable evidence of potential benefit.
In this case, although the medicinal product will be used
in pediatric patients, there is less urgency
than in the previous cases and studies would usually
begin at later phases of clinical development
or, if a safety concern exists, even after substantial post
marketing experience in adults.
1
2
3
8 of 33

11. iv. Types
Of Studies
When a medicinal product is studied in
pediatric patients in one region, the
intrinsic (e.g., pharmacogenetic) and
extrinsic (e.g., diet) factors that could
impact on the extrapolation of data to
other regions should be considered.
9 of 33

12. Pharmacokinetics
Pharmacokinetic studies in the pediatric population are generally
conducted in patients with the disease.
Dosing recommendations for most medicinal products used in the
pediatric population are usually based on milligram (mg)/kilogram (kg)
body weight up to a maximum adult dose.
For some medications (e.g.,medications with a narrow therapeutic
index ) surface-area-guided dosing may be necessary
10 of 33

13. Efficacy
• The principles in study design, statistical considerations
and choice of control groups detailed in ICH E6, E9, and
E10 generally apply to pediatric efficacy studies.
• Where efficacy studies are needed, it may be necessary
to develop, validate, and employ different endpoints for
specific age and developmental subgroups.
• In pediatric patients with chronic diseases, the response
to a medicinal product may vary among patients
11 of 33

14. Safety
• Unintended exposures to medicinal products (accidental ingestions, etc.) may provide
the opportunity to obtain safety and pharmacokinetic information and to maximize
understanding of dose-related side effects.
• Because developing systems may respond differently from matured adult organs, some
adverse events and drug interactions that occur in pediatric patients may not be
identified in adult studies.
• Long-term studies or surveillance data, either while patients are on chronic therapy or
during the posttherapy period, may be needed to determine possible effects on skeletal,
behavioral, cognitive, sexual, and immune maturation and development.
12 of 33

15. Post-marketing
Information
• The pediatric database is limited at the time of approval.
Therefore, post-marketing surveillance is particularly
important.
• Post-marketing surveillance and/or long-term follow-up
studies may provide safety and/or efficacy information
for subgroups within the pediatric population or
additional information for the entire pediatric
population.
13 of 33

16. Age Classification of Pediatric
Patients
14 of 33

17. ETHICAL ISSUES
IN PEDIATRIC
STUDIES
15 of 33

18. Institutional Review board /
Independent Ethics Committee
• The roles and responsibilities of IRB’s/IEC’s as detailed in
ICH E6 are critical to the protection of study
participants
• There should be IRB/IEC members or experts consulted
by the IRB/IEC who are knowledgeable in pediatric
ethical, clinical, and psychosocial issues.
16 of 33

19. Consent And Assent
A pediatric subject is legally unable to provide
informed consent. Therefore pediatric study
participants are dependent on their
parent(s)/legal guardian to assume responsibility
for their participation
in clinical studies.
17 of 33

20. Recruitment
Recruitment of study participants should
occur in a manner free from inappropriate
inducements either to the parent(s)/legal
guardian or the study participant.
An attempt should be made to
include individuals representing
the demographics of the region
and the disease being studied.
18 of 33

21. Minimizing Risk
Mechanisms should be in
place to ensure that a
study can be rapidly
terminated should an
unexpected hazard be
noted.
Investigators should be fully
aware of all relevant preclinical
and clinical toxicity of the
medicinal product.
In designing studies, every
attempt should be made to
minimize the number of
participants and of
Procedures.
19 of 33

22. Minimizing Distress
Practical considerations should be made to
ensure that participants’ experiences in
clinical studies are positive and to minimize
discomfort and distress.
Repeated invasive procedures
may be painful or frightening.
Studies designed and
conducted by
Personnel knowledgeable and skilled in
dealing with the pediatric population and its
age-appropriate needs, including skill in
performing pediatric procedures
20 of 33

23. ADDENDUM TO
ICH E11
21 of 33

24. Scope and Objective
An approach to the safe,
efficient, and ethical study of
medicinal products in the pediatric
population.
Scope
Objective
To complement and provide
clarification and current regulatory
perspective on topics in pediatric
drug development.
22 of 33

25. Regional differences in some instances limit the ability of health authorities to align requirements for pediatric
product development. To address such differences, timely and efficient drug development requires a common
scientific approach for which the following questions should be considered:
● What is the medical need in one or more pediatric populations that the drug could address?
● Who are the appropriate pediatric populations or subgroups that could be considered?
● What are the knowledge gaps that should be addressed to establish the safe and effective use of the drug?
● What clinical studies and/or methodological approaches could be considered?
● Are there different formulations/dosage forms or delivery devices that will be needed for specific pediatric
subgroups, both to facilitate an optimal dose-finding strategy, and for treatment of pediatric patients in
different subgroups?
A common scientific approach, not common regional requirements, is at the
cornerstone of efficient pediatric drug development
COMMONALITY OF SCIENTIFIC APPROACH FOR PEDIATRIC
DRUG DEVELOPMENT PROGRAMS
23 of 33

26. Approaches To
Optimize Pediatric
Drug Development
24 of 33

27. Use of Existing Knowledge
• Existing knowledge about a drug under development includes
evidence already or concurrently generated in adult and pediatric
populations with similar or other relevant diseases or conditions.
• Existing knowledge also integrates nonclinical data, data about
related compounds, disease pathophysiology, consideration of the
developmental physiology, and clinical data from the pediatric
population or subgroup.
25 of 33

28. • “Pediatric extrapolation” is defined as an approach to
providing evidence in support of effective and safe use
of drugs in the pediatric population when it can be
assumed that the course of the disease and the
expected response to a medicinal product would be
sufficiently similar in the pediatric and reference (adult
or other pediatric) population.
• Additional pediatric safety data are usually required, as
existing data may only provide some information
about potential safety concerns related to the use of a
drug in the pediatric population
Use of Extrapolation
26 of 33

29. • The usefulness of M&S in pediatric drug development
includes, but is not limited to, clinical trial simulation,
dose selection, choice and optimization of study
design, endpoint selection, and pediatric extrapolation.
• It is particularly critical to consider the maturation of
organ systems with the understanding that data from
older subgroups may not necessarily be informative
for the younger subgroups.
• Risk assessment is a critical part of M&S.
Use Of Modelling and
Simulation
27 of 33

30. Practicalities In The Design And
Execution Of Pediatric Clinical Trials
Outcome
Assessments
• Necessary to develop, validate,
and employ different endpoints
for specific age and
developmental subgroups.
• Standardized measurement,
collection, analysis, and reporting
of outcome assessments are
encouraged to optimize pediatric
drug development.
Feasibilty
• Implementing clinical
trial operational
strategies ,development
of master protocols.
• Adherence to Good
Clinical Practice (ICH E6)
should result in improved
feasibility.
Long – Term
Clinical Aspects
• Long-term effects of drug
treatment in children can include
impacts on development,
growth, and/or maturation of
organ/system function.
• Regular follow-up measurements
should be planned and discussed
with regulatory authorities.
28 of 33

31. ii. Pediatric
Formulations
29 of 33

32. • More than one dosage form of the active pharmaceutical
ingredient (API) and/or strengths may be needed to
cover the range of pediatric populations.
• The setting where the product is likely to be
administered should be considered - For example, long
acting formulations may be beneficial in settings where the
caregiver is not always available (e.g., school, nursery)
• Considerations should include the ease of accurate dose
measurement and the capability to deliver small volumes
of liquids to minimize the risk for dosing errors,
especially in neonates, infants and young children.
Dosage and Administration
30 of 33

33. Excipients
• The use of excipients in pediatric medicines should take into
account factors such as age, weight, maturity, frequency of dosing,
intended duration of treatment, and potential for additional
excipient exposure from commonly co-administered medicines.
• The use of excipients and their quantity in a formulation should
minimize risk and ensure product performance, stability,
palatability, microbial control, and dose uniformity.
• When selecting excipients, one should always consider the
potential impact on absorption and bioavailability of the API.
31 of 33

34. • Taste masking is often needed to improve the
palatability of the API.
• As pediatric drug development can benefit global
populations, the target for taste masking should not only
be focused on ensuring that the preparation does not
taste unpleasant. Ideally, the preparation should have a
neutral taste or a taste with broad cultural acceptance.
• Alternative dose administration strategies should be
considered for pediatric populations who cannot be
accommodated by the intended dosage form (e.g.,
segmenting or crushing tablets, co-administration with
food or liquids)
Palatability and
Acceptaibility
32 of 33

35. • For neonates, environmental conditions and equipment
used for drug administration (e.g., enteral feeding tubes)
may have an effect on drug delivery and bioavailability.
• Formulation requirements for neonates warrant special
attention, such as its effects on electrolyte, fluid or
nutritional balance.
• Intramuscular preparations should be avoided
• While parenteral formulations may be used in neonates,
it should be considered that their use often necessitates
careful monitoring.
Neonates
33 of 33

36. THANKYOU !
Soham Patil
Drug Regulatory Affairs